ENT - Level 1 Flashcards
Definition of otitis media?
- Middle ear inflammation
Definition of recurrent otitis media with effusion?
- Recurrent ear infections – secretory otitis media (Glue ear)
Middle ear effusion without the symptoms of acute otitis media
How common is otitis media?
o Bacterial (most commonly)
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes
o Viral
RSV, rhinovirus, adenovirus, influenza and parainfluenza
Causative organisms of otitis media?
o Bacterial (most commonly)
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes
o Viral
RSV, rhinovirus, adenovirus, influenza and parainfluenza
Symptoms of otitis media?
- May follow URTI
- Symptoms
o Rapid onset pain in the ear
o Fever
o Irritability
o Vomiting
o Deafness
Signs of otitis media?
o Bright red and bulging with loss of normal light reflection
o Occasional acute perforation with pus in ear canal
o Look for swelling over mastoid – mastoiditis secondary
Diagnosis of acute otitis media?
o Acute onset – earache, holding, tugging ear or non-specific symptoms
o Otoscopy – red, tallow or cloudy tympanic membrane with bulging and loss of normal landmarks, air fluid level behind tympanic membrane or perforation
When to admit of otitis media for specialist assessment from primary care?
o Severe systemic infection
o Acute complications of otitis media (meningitis, mastoiditis, incracranial abscess, sinus thrombosis, facial nerve paralysis)
o Child <3 months with temperature >38
Management of otitis media - general advice?
o Analgesia (regular paracetamol and ibuprofen) o Most cases resolve spontaneously within 3 days but can be up to 1 week
Management of otitis media - antibiotics?
o If very unwell, have symptoms and signs of illness or high risk:
Immediate antibiotic
o For those who may benefit from antibiotics, consider delayed prescription, no prescription or immediate
Amoxicillin for 5-7 days
Can give clarithromycin or erythromycin if penicillin allergic
Management of otitis media - if perforation?
o Follow up with ENT and do not swim
Management of otitis media - if treatment failure?
o If not taken antibiotic – give prescription
Amoxicillin for 5-7 days
Can give clarithromycin or erythromycin if penicillin allergic
o If taken first-line antibiotics, give co-amoxiclav for 5-7 days
o If symptoms persist despite two courses of antibiotics – refer to ENT
Management of otitis media if persistent symptoms - hearing loss with no pain or fever?
Active observation for 6-12 weeks
Two hearing tests using pure tone audiometry >3 months apart
Management of otitis media if persistent symptoms - hearing loss with no pain or fever - when to refer?
o Hearing loss impacting child development
o Hearing loss >61dB
o Significant hearing loss on two occasions
o Tympanic membrane abnormal
o Foul-smelling discharge (cholesteatoma)
o Down’s syndrome or cleft palate
Management of otitis media if persistent symptoms - hearing loss with no pain or fever - non-surgical and surgical management?
o Active observation for 3 months with regular audiology follow up
o Hearing aids
o Autoinflation
o Myringotomy with Grommet insertion, with or without adenoidectomy
If persistent bilateral OME over 3 months with hearing in better ear <25-30dB averaged at 0.5, 1, 2 and 4 kHz or if affecting development
Adenoidectomy only if frequent URTIs
Follow up until grommets extruded and eardrum healed
Management of otitis media if persistent symptoms - discharge from ear canal for 2 weeks?
Refer to ENT assessment – given steroids and antibiotics and intensive cleaning of ear
Complications of otitis media?
- Mastoiditis
- Meningitis
Definition of pharyngitis?
local inflammation of oropharynx with enlarged and tender lymph nodes
Definition of tonsilitis?
form of pharyngitis where there is intense inflammation of the tonsils, often with purulent exudate
Definition of influenza?
acute respiratory illness caused by RNA Orthomyxoviridae viruses
Epidemiology of URTIs?
- Highest incidence in children and young adults
- More common in winter
- URTI are 80% of respiratory infections
Causative organisms of common cold (coryza)?
Rhinovirus, coronaviruses, influenza virus, parainfluenza and RSV (however RSV usually causes acute bronchiolitis)
Lasts 1 ½ weeks
Common – adults 2-3x colds per year, children 5-6x colds per year
Causative organisms of Pharyngitis/tonsilits?
Adenoviruses, enteroviruses, rhinoviruses, influenza types A and B, parainfluenza, group A B-haemolytic streptococcus, HSV-1, EBV, Candida
Non-infectious – physical irritation, hayfever, GORD, Kawasaki’s disease, oral mucositis
Lasts 1 week
Causative organisms of epiglottitis?
Hib
Causative organisms of influenza?
Type A – frequent and more virulent, local outbreaks and epidemics
Type B – co-circulates with A during yearly outbreaks, less severe
Type C – mild/asymptomatic infection similar to common cold
Peak during winter months
Symptoms of tonsillitis/pharyngitis?
o Fever (+/- febrile convulsions) o Painful throat o Exudate present in bacterial tonsillitis o Earache and nasal discharge o Difficulty feeding and drinking
Symptoms of common cold?
o Sore throat
o Nasal irritation, congestion, nasal discharge and sneezing
o Cough
o Hoarse voice
o General malaise
o Fever, myalgia and headache less common
Symptoms of uncomplicated influenza?
Coryza, cough, fever, Diarrhoea, headache, myalgia, malaise, sore throat, photophobia, conjunctivitis
Symptoms of complicated influenza?
Signs and symptoms requiring hospital admission, LRTIs, CNS involvement, exacerbation of underlying medical condition
Assessment of tonsillitis/pharyngitis?
o Clinical examination – pus on tonsils indicates bacterial infection
o Neck – think bacterial infection if tender lymphadenopathy
o FeverPAIN score
o Centor Criteria
What is FeverPain score in tonsillitis?
Fever >38 Purulent (exudate on tonsils/pharyngeal) Attend rapidly (<3 days) Inflamed tonsils No cough/coryza • Score 4 or 5 - Abx
What is Centor Criteria in tonsillitis?
Tonsilllar exudate Tender anterior cervical lymphadenopathy Fever Absence of cough • 3 or 4 needs Abx
Investigations in influenza?
o Laboratory diagnosis for complicated influenza (in hospital)
o Viral PCR
o Alternatives – serology and culture
Management of tonsillitis - hospital admission needed when?
Breathing difficulty
Dehydration
Peri-tonsillar abscess or cellulitis
Sepsis
Management of tonsillitis - if on DMARDs, carbimazole, chemotherapy, HIV, asplenia?
Seek immediate advice
FBC urgently
Management of tonsillitis - general advice?
Majority caused by viral infections
40% of symptoms resolve within 3 day and 85% within 1 week
Symptomatic relief
• Keep hydrated
• Paracetamol and ibuprofen
• Avoid hot drinks – worsen pain
Children return to school after fever resolved and no longer feel unwell or after 24h of Abx
Management of tonsillitis - Antibiotics?
If positive culture or Centor criteria 3 or 4 or FeverPAIN 4 or 5
If FeverPAIN 2 or 3 – consider delayed prescription
Prescribe penicillin V (phenoxymethylpenicillin 500mg QDS) for 10 days
Alternatives: erythromycin or clarithromycin for 5 days
AVOID AMOXICILLIN AS CAUSES RASH IN EBV
Management of tonsillitis - recurrent tonsillitis?
o If recurrent tonsillitis (>7 episodes per year for one year, >5 episodes per year for 2 years or >3 episodes per year for 3 years)
Refer to ENT for tonsillectomy advice
Criteria for referral to ENT for tonsillectomy?
> 7 episodes per year for one year
> 5 episodes per year for 2 years
> 3 episodes per year for 3 years
Management of common cold - general advice?
o Self-limiting and symptoms peak around 2-3 days then decrease up to 1 week or 2 weeks for young children, cough may last for 3 weeks
Management of common cold - symptomatic relief?
- Keep hydrated
- Paracetamol and ibuprofen
- Avoid hot drinks – worsen pain
- Steam inhalation relieves congestion (or sitting in hot shower)
- Intranasal decongestants, cough medicine available OTC
Management of common cold - hygiene methods?
- Washing hands frequently with soap and water
* Avoid sharing towels
Management of common cold - follow up?
Come back if symptoms worsen or persist longer than 7/14 days
Management of influenza - prevention with seasonal vaccine - when to give?
• All people >65 (trivalent)
• All people 6m-65y if in following groups (quadrivalent):
o Chronic respiratory illness
COPD, bronchiectasis, CF, ILD, pneumoconiosis, BPD, asthma needed ICS
o Chronic heart disease
CHD, hypertension with cardiac complications, HF, regular medication for IHD
o CKD (Stage 3-5), nephrotic syndrome, transplant
o Chronic liver disease – cirrhosis, biliary atresia, chronic hepatitis
o Neurological
Stroke/TIA, at risk of co-morbidity exacerbated by flu (CP, LD, PD, MS, MND, degenerative disease, polio)
o DM type 1 and 2 needing OHA/insulin
o Immunosuppressed
Chemotherapy, bone marrow transplant, HIV, systemic steroids (>1m of 20mg daily), myeloma, asplenia, or SCD
o Pregnant women
o BMI>40
Management of influenza - symptomatic relief?
- Keep hydrated
- Paracetamol and ibuprofen
- Rest in bed
- Stay off work/school until feel able to attend
Management of influenza - antiviral therapy criteria?
o Antiviral (oral oseltamivir or inhaled zanamivir) if all of following apply:
National surveillance scheme indicate influenza circulating
Person at ‘high risk’ group
• Aged >65, <6m or pregnant women
• People with following conditions:
• Asplenia, COPD, bronchiectasis, CF, ILD, pneumoconiosis, Asthma needing inhaled corticosteroids
• HF, CHD, IHD
• CKD (Stage 3-5), chronic liver disease
• Stroke/TIA
• DM
• Immunosuppressed – chemotherapy, bone marrow transplant, HIV, systemic steroids (>1m of 20mg daily), myeloma
• BMI >40
Person can start treatment within 48 hours of onset of symptoms (36 with zanamivir with children)
Management of influenza - follow up?
Within 1 weeks if >65 or <6m to confirm improving
After 1 week if not improving
Management of influenza - admission to hospital if?
Complication – pneumonia
High risk of complications
<2 years and at risk group
Febrile seizure
Management of influenza - post-exposure prophylaxis given when and what?
• National surveillance scheme indicates influenza circulating
• Person exposed (in same household or residential setting)
• At risk group and:
o Not vaccinated since previous season
o Vaccination not well-matched to circulating scheme
o <14 days between vaccination and date of contact
• Person can start treatment within 48 hours of onset of symptoms (36 with zanamivir with children)
Oral oseltamivir or inhaled zanamivir for 10 days
Complications of tonsilitis/cold?
o Otitis Media
o Sinusitis
o Peritonsillar abscess (quinsy)
o Para-pharyngeal abscess
Complications of influenza?
o Bronchitis o Exacerbation of asthma or COPD o Otitis media o Pneumonia o Sinusitis o Myocarditis, pericarditis o Febrile convulsions o Myalgia, rhabdomyolysis o GBS o In pregnancy – preterm labour and low birth weight
